Southwest Licking
Local School District
927-A South Street
Pataskala, OH 43062
740-927-3941
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Harassment/Bullying Report
What school does this involve?
Watkins Memorial High School
Watkins Middle School
Etna Elementary
Pataskala Elementary
Kirkersville Elementary
SWL Kindergarten Center
Student's name being bullied:
Date of Report:
Date of Alleged Harassment:
Location of Alleged Harassment:
Name of alleged harasser:
Description of Incident(s):
Name of Witness(es), if any:
To validate your submission, please answer the following math problem:
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